NHS needs more advanced paramedics to ease A&E pressure

Paramedics with advanced training can reduce the number of patients admitted to hospital unnecessarily, says NICE.

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Image source: Carl Spencer – Flickr // CC BY-NC 2.0

NICE is recommending the NHS provides more advanced paramedic practitioners (APPs) to relieve pressure on emergency departments, in new draft guidance. Evidence reviewed by NICE shows that using APPs can reduce hospital admissions by 13% compared with standard paramedics.

The draft guidance also makes wider recommendations about emergency and acute medical services to standardise care across the NHS. It supports NHS England’s Five Year Forward View for the future of emergency medical services.

Full story available here

Antimicrobial stewardship to optimize antimicrobial use for outpatients at emergency department

Antimicrobial stewardship programs (ASPs) have proven to be effective in optimizing antibiotic use for inpatients. However, Emergency Department (ED)’s fast-paced clinical setting can be challenging for a successful ASP | The Journal of Hospital Infection

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Aim: In April 2015, an ASP was implemented in our ED and we aimed to determine its impact on antimicrobial use for outpatients.

Methods: Monocentric study comparing the quality of antibiotic prescriptions between a one-year period before ASP implementation (November 2012 to October 2013) and a one-year period after its implementation (June 2015 to May 2016).

For each period, antimicrobial prescriptions for all adult outpatients (hospitalized for <24hours) were evaluated by an infectious disease specialist (IDS) and an ED physician to assess compliance with local prescribing guidelines. Inappropriate prescriptions were then classified.

Findings: Before and after ASP, 34,671 and 35,925 consultations were registered at our ED, of which 25,470 and 26,208 were outpatients. Antimicrobials were prescribed in 769 (3.0%) and 580 (2.2%) consultations, respectively (p<0.0001). There were 484 (62.9%) and 271 (46.7%) (p<0.0001) instances of non-compliance with guidelines before and after ASP implementation. Non-compliances included unnecessary antimicrobial prescriptions, 197 (25.6%) vs. 101 (17.4%) (p<0.0005); inappropriate spectrum, 108 (14.0%) vs. 54 (9.3%) (p=0.008); excessive treatment duration, 87 (11.3%) vs. 53 (9.1%) (p>0.05); and inappropriate choices, 11 (1.4%) vs. 15 (2.6%) (p>0.05).

Conclusions: The implementation of an ASP dramatically decreased the number of unnecessary antimicrobial prescriptions, but had little impact on most other aspects of inappropriate prescribing.

Full reference: Dinh, A. et al. (2017) Impact of an antimicrobial stewardship program to optimize antimicrobial use for outpatients at emergency department. The Journal of Hospital Infection. Published online: 8th July 2017

Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury

This study aims to determine the prevalence and potential risk factors of acute and chronic post-traumatic headache (PTH) in patients with mild to moderate traumatic brain injury (TBI) | Emergency Medicine Journal

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Objectives: Acute PTH (aPTH) is defined by new or worsening of pre-existing headache occurring within 7 days after trauma, whereas chronic PTH (cPTH) is defined as persisting aPTH >3 months after trauma. An additional goal was to study the impact of aPTH and cPTH in terms of return to work (RTW), anxiety and depression.

Conclusions: PTH is an important health problem with a significant impact on long-term outcome of TBI patients. Several risk factors were identified, which can aid in early identification of subjects at risk for PTH.

Full reference: Tansel, Y. et al. (2017) Risk factors and outcomes associated with post-traumatic headache after mild traumatic brain injury. Emergency Medicine Journal. Published Online First: 8th July 2017

A&E cuts will hit 23m people, British Medical Association says

Nearly 23 million people in England – more than 40% of the population – could be affected by proposed cuts to A&E departments, doctors are warning | BBC News

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The analysis of NHS plans by the British Medical Association also warned the changes were being rushed through without the evidence they will work. The proposals have been put forward by local managers seeking to make savings under the direction of NHS England. Bosses have argued services in the community will be boosted in return.

Under the so-called “sustainability and transformation programme” (STP), England has been divided into 44 areas and each asked to come up with its own proposals.

After analysing local plans, the BMA found:

  • 18 of them, covering a population of 22.9 million, involved the closing or downgrading of an A&E department
  • 14 of them, responsible for 17.6 million patients, propose closing or merging a hospital
  • 13 of them, covering a population of 14.7 million, have put forward closing hospital beds

Read the full news story here

Emergency Department Escalation in Theory and Practice

Escalation policies are used by emergency departments (EDs) when responding to an increase in demand (eg, a sudden inflow of patients) or a reduction in capacity (eg, a lack of beds to admit patients) | Annals of Emergency Medicine

The policies aim to maintain the ability to deliver patient care, without compromising safety, by modifying “normal” processes. The study objective is to examine escalation policies in theory and practice.

Editor’s Capsule Summary:

  • What is already known on this topic

Care delivery organizations commonly develop “escalation policies” for managing crowding and surges in emergency department (ED) demand. The effectiveness of these policies has seldom been studied.

  • What questions this study addressed

This study used mixed methods to identify common patterns in escalation policies in UK EDs and to evaluate how well they performed in practice.

  • What this study adds to our knowledge

Formal escalation policies often presumed the availability of resources that were missing or degraded when escalation was needed. Consequently, the actual practice of managing crowding deviated from that inscribed in policy.

  • How this is relevant to clinical practice

Recognizing and monitoring the gap between formal policies and actual practice should help in the development of more realistic and useful escalation policies.

Full reference: Back, J. et al. (2017) Emergency Department Escalation in Theory and Practice: A Mixed-Methods Study Using a Model of Organizational Resilience. Annals of Emergency Medicine. Published online: 26 June 2017

Patient and service-provider perspectives for treating primary care complaints in urgent care settings

An investigation into why patients chose to attend two, nurse-led, minor injury units (MIUs) to access primary healthcare services rather than attend their GP practice | International Emergency Nursing

Highlights:

  • Patients with non-urgent conditions are increasingly attending urgent care providers in the UK.
  • Consumerist notions of choice and expediency influence healthcare decision making.
  • Patients seem to be acting rationally in response to healthcare policy promises.
  • Providing treatment establishes precedent and expectation for future care.
  • Co-located primary care, working alongside ENP services, offer benefits for local communities.

Full reference: Sturgeon, D. (2017) Convenience, quality and choice: Patient and service-provider perspectives for treating primary care complaints in urgent care settings. International Emergency Nursing. Published online: 26 June 2017

Occupational stress in the ED

Occupational stress is a major modern health and safety challenges. While the ED is known to be a high-pressure environment, the specific organisational stressors which affect ED staff have not been established | Emergency Medicine Journal

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Methods: We conducted a systematic review of literature examining the sources of organisational stress in the ED, their link to adverse health outcomes and interventions designed to address them. A narrative review of contextual factors that may contribute to occupational stress was also performed. All articles written in English, French or Spanish were eligible for conclusion. Study quality was graded using a modified version of the Newcastle-Ottawa Scale.

Results: Twenty-five full-text articles were eligible for inclusion in our systematic review. Most were of moderate quality, with two low-quality and two high-quality studies, respectively. While high demand and low job control were commonly featured, other studies demonstrated the role of insufficient support at work, effort–reward imbalance and organisational injustice in the development of adverse health and occupational outcomes. We found only one intervention in a peer-reviewed journal evaluating a stress reduction programme in ED staff.

Conclusions: Our review provides a guide to developing interventions that target the origins of stress in the ED. It suggests that those which reduce demand and increase workers’ control over their job, improve managerial support, establish better working relationships and make workers’ feel more valued for their efforts could be beneficial. We have detailed examples of successful interventions from other fields which may be applicable to this setting.

Full reference: Basu, S. et al. (2017) Occupational stress in the ED: a systematic literature review. Emergency Medicine Journal. 34:441-447.